Why eradicating Malaria in Africa requires a specific approach and new tools?

Africa has been described as the continent on the rise. In 2014, the World Bank hailed the continent for two decades of steady economic growth that “represent[ed] a quantum jump”. Five years later, the World Malaria Report 2019 paints a grimmer picture of the continent from the lens of malaria prevalence: out of the 228 million cases and 405,000 deaths in 2018 around the world, 85% occurred in just 19 countries, all being in sub-Saharan Africa, except one (India). Why is the “Africa Rising” narrative not translating into rising gains and investments in fighting malaria, when malaria kills African youth, weakens the whole population and debilitates economies?

While malaria remains a major cause of morbidity and mortality worldwide, its burden is heaviest in resource-poor settings and in populations with low access to care. In Asia and South America, many countries have been moving towards elimination; ten countries have been certified malaria-free since 2000 and a further 10 countries remain on track to achieve their elimination goals.

This disparity in progress between regions can be attributed to a combination of technical, operational and financial differences. Africa must overcome major issues and unique challenges; in particular, limited healthcare financing; poor healthcare infrastructure; and the uncertain impact of climate change.

Healthcare financing

Africa continues to rely on international donor funding for financing its malaria control programmes. This aid has plateaued in recent years. Limited domestic resources impose constraints for programmatic implementation and restrain human resources available to effectively prioritise interventions. As noted by the World Malaria Report 2019, of the US$ 9.4 billion funding directed at the 11 high burden to high impact countries (HBHI) between 2010-2018, 82% (US$ 7.7 billion) came from international sources. This funding does not include the cost of health workers.

In a 2016 WHO report, Public Financing for Health in Africa: from Abuja to the SDGs, it was noted that even though most African countries had improved their budget allocations to health over the past 15 years, health spending was sometimes de-prioritized even as state revenues grew, and were marked with fluctuations in financial flows hence limiting the sector’s capacity to effectively plan and implement. With minimal government spending on healthcare (up to 44%), “more than 37% of all of Africa’s health spending comes from out-of-pocket payments.” This scenario has significant impacts as up to 38% of Africans delay or forego health care and at least 11% experience catastrophic healthcare spending every year (Closing Africa’s health financing gap, 2019).

Healthcare infrastructure

With limited funding comes operational challenges that include: the complexity of delivering a set of partially-efficacious intervention tools in remote areas; behavioural barriers to achieving high levels of coverage of these tools; and the movement of people harbouring asymptomatic infection and spatial complexities. The inaccessibility of remote areas and regions experiencing political instability and/or conflict affects both the ability to maintain coverage and the wider displacement of populations.

Weak and under-resourced health systems, human resources limitations, inaccessibility to malaria control services and poor surveillance systems have significant impacts on malaria control. The health workforce in Africa is poorly resourced with inadequate numbers, quality and management posing a major challenge (WHO, 2018). While Africa bears “more than 24% of the global burden of disease, it has access to only 3% of health workers and 1% percent of health financing”. Furthermore, these disproportionate healthcare resources must be distributed among the major diseases plaguing the continent including HIV/AIDS, TB, malaria and other emerging infectious diseases. Emergency healthcare for disease outbreaks such as Ebola often divert the limited available resources leaving the sector struggling even further to prioritize malaria control (Walker et al, 2015)¹.

Climate change and the future of malaria in Africa

The increased frequency of epidemics in Africa is now being closely linked to climate change. The 1.5 Health Report of the Intergovernmental Panel on Climate Change (IPCC) indicates that: “There is strong evidence that changing weather patterns associated with climate change are shifting the geographic range, seasonality, and intensity of transmission of climate-sensitive infectious diseases.” Evidence seems to suggest that climate change increases the risk of malaria transmission (Le et al, 2019)².

COVID and malaria

Recent reports³ have noted the potential impact of COVID on malaria because of the delay in bednet distribution programs, confusion in diagnosis because of similarity of symptoms and a general competition on already fragile health care systems. This uncertainty looms large on African countries.

Target Malaria: A novel solution

How is Africa going to overcome these challenges and reduce the burden malaria places on its economies? Most of the tools used to tackle malaria today were developed in the last century or even earlier. With global malaria infections and death rates remaining virtually unchanged since 2015, WHO has recognized acceleration in research and development (R&D) in new tools for malaria prevention and treatment are key to eradicating malaria globally (Global Technical Strategy for Malaria 2016-2030). Currently, less than 1% of health R&D funding is going into developing tools to tackle malaria. Novel solutions are required to scale up existing tools.

Target Malaria is a research consortium that promises to reduce the burden of malaria in Africa by developing innovative, cost-effective and sustainable genetic technologies in complementarity with the existing tools. The project aims at reducing population of malaria-transmitting mosquitoes thus reducing malaria transmission. Target Malaria is co-developing both its technologies and associated knowledge and our teams work across multiple locations in Africa, Europe and North America. Despite being at an early stage of research and development, Target Malaria’s innovative technology could be the next breakthrough towards a world free of malaria.

Read Dr. Mamadou Coulibaly’s biography on our recent article celebrating ‘Target Malaria’s champions’.

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^{1 – Walker PGT, White MT, Griffin JT, et at (2015) Malaria morbidity and mortality in Ebola-affected countries caused by decreased health-care capacity, and the potential effect of mitigation strategies: a modelling analysis. Lancet Infect Dis.; 15: 825–32. https://doi.org/10.1016/S1473-3099(15)70124-6}

^{2 – Le PVV, Kumar P, Ruiz MO, Mbogo C, Muturi EJ (2019) Predicting the direct and indirect impacts of climate change on malaria in coastal Kenya. PLoS ONE 14(2): e0211258. https://doi.org/10.1371/journal.pone.0211258}

^{3 – Hogan AB, Jewell BL, Sherrard-Smith E, et al. (2020) Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study. Lancet Glob Health; published online July 13. https://doi.org/10.1016/S2214-109X(20)30317-X}